REASONS FOR USE
Suggestion (in its most potent form—hypnosis) establishes the capacity for conditioning and formation of habit patterns that exceeds those that are developed at ordinary levels. Thus, reassurance, reeducation, and deconditioning are more durable than when employed at nonhypnotic levels. When repetitive reinforcement through autohypnosis is utilized, healthy responses become autonomous. It is this self-sustaining feature of hypnotic conditioning that reverses faulty thinking processes and behavior patterns responsible for maintenance of stress associated with a wide variety of psychosomatic disorders. Hypnosis per se is not a therapeutic modality, but rather is a technic used within the total approach of an overall therapeutic regimen.
Thus, there is no reason why hypnotic conditioning cannot be combined with drugs when the latter are indicated as part of a comprehensive treatment program. For instance, hypnotic conditioning can reduce the fears and anxieties which exacerbate attacks in cardiacs to instill optimism and feelings of well being. This can mean the difference between life and death. Recognized, but not generally appreciated is that preoccupation with structural heart disease can spark a chain reaction leading to generalized anxiety and harmful sequelae.
However, even when hypnotic conditioning is used alone for symptomatic control, it can be employed in the same judicious manner as a drug. Is not the bulk of medical therapy directed toward symptom relief? And why should not psychogenically based symptoms removed by hypnosis respond similarly to those eliminated by physical and drug measures? There are no well-controlled studies to support the contention that other symptom-equivalents take the place of the original one.
For refractory cases, hypnotic conditioning can be incorporated with other types of psychotherapy, such as behavior therapy. It also can be employed by psychodynamically oriented physicians to provide an understanding of what the symptom means to the patient (secondary gain value); how much of it he wishes to yield; and, most important, how he can face his problems and life situations in a more realistic and mature manner rather than resorting to infantile methods of coping with them.
Hypnotic conditioning also modifies or ameliorates organic conditions having a large psychogenic component; this occurs irrespective of whether the latter produced the illness or is the result of an organic disease. Each case is different because of the individual peculiarities of man's adaptive responses, conditioned as he is by the complexity of life's experiences. Therefore, whenever possible, a detailed life history is necessary to disclose the degree of emotional involvement, the conditions under which the pathophysiologic processes developed, and the strengths and weaknesses of the personality. This helps determine the degree of emotional support that will best motivate the patient during the initial phases of therapy when progress is imperceptible. Such an approach also helps structure the therapeutic goals. A number of investigators have discussed the role of hypnosis to psychosomatic disorders.
Hypnotherapy should be used only in carefully evaluated cases that have been screened by a thorough physical examination to establish the diagnosis. However, it is not a panacea for the illnesses of mankind.
Hypnorelaxation generally expedites therapy by counterconditioning anxiety, particularly in those who are affect-blocked; the increased relaxation, concentration, and cooperation allow them to talk more freely about their problems. As a result, the greater self-objectivity provides new ideas and understandings of the nature of their symptoms. Where indicated, in suitable subjects, posthypnotic suggestions temporarily can suppress a symptom or “hold it on leash” until the inordinate need for the symptom is understood and ready to be relinquished.
Autohypnosis also can be employed for self-exploration—when the symptom is removed by the patient rather than by the therapist, this accomplishment leads to longer lasting results. Artificial, hypnotically induced conflicts, in amenable subjects, often help resistant individuals recognize the “how” and “why” of their emotionally based disorders. After this knowledge is obtained, appropriate posthypnotic suggestions can be used to channel the harmful drives produced by a symptom-complex into more constructive outlets. Often, “trading down” or substituting a more innocuous symptom is helpful in this regard (see Chap. 50).
A prime indication for hypnotherapy is the hypochondriasis induced by alarmist health columns, magazine articles or remarks of well-meaning friends. The doctor, too, by ill-considered statements, a “polypragmatic” approach, an inadequate history or a careless physical examination, can unwittingly generate anxiety.
Another distinct advantage of hypnotic conditioning is that firmly established rapport acts to “bind the anxiety-ridden patient in therapy” during the initial phases of any psychotherapeutic relationship. It is at this crucial period that most emotionally disturbed individuals, through one rationalization or another, defeat the therapist by prematurely breaking off treatment, with the result that they then can cling to their neurotic behavior patterns without guilt and tension.
PSYCHOSOMATIC CARDIOVASCULAR DISORDERS
Essential Hypertension
In essential hypertension, stress due to chronic and inhibited rage is considered one important factor. The symptom often represents the individual's “cold war with his environment,” manifesting itself as a sympatheticoadrenal, salt-retaining, blood-pressureraising response. Since relaxation, sedatives and tranquilizers temporarily reduce the blood pressure, a stress factor apparently is operative.
Posthypnotic suggestions, together with sensory-imagery conditioning under autohypnosis, potentiate drug therapy to reduce the blood pressure. This cannot lightly be dismissed “as nothing but suggestion,” as, in this state, conditioning phenomena, as disturbed feedback mechanisms, faulty associative learning patterns, and harmful stimuli, can be significantly altered. Thus it can be understood why this type of hypnotherapy is more effective than directive hypnosis. This new approach also is far superior to the old bromides such as, “You must take it easy and learn to relax.” Or, “Why don't you just quit worrying?” Individuals with other types of hypertension can be taught specifically how to relax and to develop a better comprehension of their problems as well as their capabilities to cope with their everyday tensions.
Often, a disarming façade of calm cooperativeness in hypertensives obscures their aggressive drives. Many are depressed, threatened and easily frustrated because of their hostile dependency needs. However, modification or correction of these needs is often a difficult task with almost any type of therapy; relapses are commonly noted. In cases in which physical rest has been prescribed, the psychic stress of merely being inactive often raises the blood pressure. Here, modified activity and mental rest by sensory-imagery conditioning and behavior therapy are an ideal combination for all types of hypertensives. Autohypnosis should be used for reinforcement. Naturally this regimen can and should be combined with appropriate medicaments.
Psychogenic Cardiac Disorders
Arrhythmias, Effort Syndrome, and Palpitation
Paroxysmal tachycardia, extrasystoles, and arrhythmias can be produced by spontaneous recall of traumatic memories. Doubt as to the integrity of the heart can result in alteration of the rate and rhythm. Fright, anxiety, and sudden shock are commonly associated with precordial pain. Spectacular results often accrue following removal of dispelling “heart disease” that never existed. It is a difficult task to convince the cardiophobic patient that his problems are psychogenic.
Deconditioning, consisting of pleasant associations under hypnosis, often can relieve functional chest pain and associated symptoms in tense and anxious patients. Reflex conditioning of the heart to produce a rise in blood pressure and tachycardia, or bradycardia, has been demonstrated (the Danini-Aschner phenomenon).69
Other functional disorders of the heart respond to hypnotic conditioning directed primarily to symptom removal.52
Hypnotic age regression has been successfully utilized to reexperience and relieve arrhythmias due to rheumatic fever in childhood.88 When the symptoms are functional in origin, hypnotic symptom removal is particularly effective.42
If the arrhythmias can be related to specific situations, the results are excellent if the patient is conditioned not to overreact to strong emotional stimuli. This is not surprising, as cortical regulatory mechanisms acting through specific nuclei of the hypothalamus affect the rate and rhythm of the heart, and are responsible for premature beats and paroxysmal tachycardia.
Suggesting conflictual situations to hypnotized patients has resulted in either the production or the elimination of extrasystoles. Creation of serene feelings eliminated the extrasystoles. Revivification of a combat scene, which resulted in abreaction of an affect-charged experience, produced complete recovery in a case of psychogenic heart disease. These cases, as well as others discussed in this book, apparently confirm Pavlov's observations that traces of past experiences are indelibly “etched” in the brain, and can be activated by the proper associational reflexes. It also appears that when some degree of abreaction of highly charged emotional material is relived under hypnosis, the resultant deconditioning significantly aids recovery.
In many instances, doctor-patient rapport is as effective as most of the vasodilating drugs in relieving even the pain of angina pectoris.11 The placebo effect of pharmacologic agents and even surgical procedures, such as the Vineberg operation in cardiac disorders, is well recognized. Therefore, if placebos are effective, then hypnotic inhibition of excitatory stimuli should afford even greater relief.
Hypnosis has been employed successfully to decrease anxiety and the likelihood of arrhythmias during cardiac catheterization.13 It has helped, at least temporarily, to interrupt cardiovascular disorders of psychosomatic origin.88
Direct suggestions under hypnosis have relieved cases of chronic palpitation. Raginsky reinduced a stoppage of the heart in a patient who had been operated for a carotid sinus syndrome several years before.71 The cardiac arrest had not occurred since the surgery. It was reproduced by posthypnotic suggestions to revivify the “attack,” and it was reexperienced with all its original manifestations and intensity. In spite of the absence of the carotid bodies, the objective findings of cardiac arrest were demonstrable in the serial electrocardiograms!
CORONARY DISEASE
Raginsky performed an immediate “hypnotic leukotomy” on several patients with coronary occlusion.71 In one case, a man developed a massive cardiac infarct while Raginsky was at the patient's home. Prompt hypnotization reduced the pain, anxiety, and shock, and the patient was rushed to the hospital. Subsequent electrocardiograms indicated definitive improvement. He attributed the successful outcome to the hypnotic relaxation, as no other measures were employed. Of course, recovery could have been due to coincidental factors.
Recent data indicate that acute or chronic stress is an important factor in the production of coronary disease, especially if obesity, hypertension, and hypercholesterolemia are present.22,28 Emotional tension per se can elevate serum cholesterol up to 35 mg. in an hour. In some cases of coronary insufficiency, it is difficult to understand how a patient can do a large amount of physical work at times and yet be unable to walk up a flight of stairs. Some sufferers have attacks while performing light physical duties and yet have no difficulties during more strenuous tasks. Levine remarks, “There is much about all this that makes one think of a conditional reflex. The number of foot-pounds of work is not the whole story.”54 In this regard, Platonov describes how cardiac output can be improved by appropriate hypnotic conditioning.70 In addition to physiological factors, angina pectoris is also determined by personality factors which have a bearing on an “angina threshold.”
Particularly pertinent to coronary disease are studies made possible by hypnotic conditioning and sensory-imagery technics to indicate that induced depression, anger, and fear are associated with an increase in the free fatty acids in the blood stream. The emotions equaled those experienced as reality situations in the past. Here is proof positive that the ability to experience sensory distortion in hypnosis is correlated with the ability to respond physiologically to hypnotically suggested emotion.
Many heart sufferers can live out their life span if they recognize their limitations, learn how to relax, and develop new interests. To minimize acute anxiety produced by aggravating situations, positive hypnosuggestions can augment tranquilizers and sedatives. Hypnosis also mobilizes faith and the “will to live.” Unfortunately, not every heart victim is susceptible to deep hypnosis. However, even light hypnosis potentiates narcotics and sedatives, and can help those who react poorly to these drugs. Unquestionably, thoughts of death and impending doom take their toll. Extreme mental anguish, by production of hyperventilation, interferes with blood oxygen tensions, increases norepinephrine output, and sets the stage for acute exacerbations. These can be reversed by hypnosis or the relaxation response. The latter probably works by diminishing excessive sympathetic activity.
POSTMYOCARDIAL INFARCTION SYNDROME
The author has had gratifying results in a selected number of patients with postmyocardial infarction syndrome. Strong reassurance and reeducation under hypnosis directed toward achieving better adjustment to their condition, together with development of glove anesthesia, relieved or reduced their fears and anxieties and thereby raised their pain threshold. Those whose symptoms were ameliorated were advised to live within their limitations. They were carefully informed that the onset of shortness of breath and anginal pains was a warning signal to be heeded. All were checked and kept on routine medication by their physicians. Dietary control as well as reduction of salt and other risk factors can be maintained by posthypnotic suggestions in those who are obese or who have diabetes or hypertension. Posthypnotic suggestions can be used for promoting exercise and abstaining from fats and cigarettes. It would be interesting to compare a group of acute coronary and postmyocardial infarction cases treated as above with those treated by standard medical procedures. It has been observed that hypnosis had a beneficial effect on the apprehension accompanying postmyocardial infarction.64 Reassurance, reeducation, desensitization guidance, and other direct support technics to get the patient rehabilitated have been used. Ego strengthening hypnotic technics can be used for the patient apprehensive of the sequelae supposedly produced during sexual intercourse.
Though hypnosis was not employed, Dunbar demonstrated that postmyocardial infarction patients who had received some type of psychotherapy outlived those who had not.20 This area offers a fertile field for investigation. Other researchers showed that hypnosis and exercise were of benefit following myocardial infarction.41 The personality profile that predisposes one to myocardial infarction has been described.28
Congestive Heart Failure
In congestive heart failure, the attacks of dyspnea are more frequent during the night when the sensory threshold is lowered. Everyone advocates complete mental and physical rest, but no one teaches patients specifically how the former can be attained. During periods of increased emotional tension, patients with congestive failure have increased sodium and water retention. The sodium output may be 20 per cent less than normal, thereby leading to decreased cardiac reserve.
In these patients, hypnorelaxation decreases stress, hyperventilation, and electrolyte retention, and often can stimulate the recovery forces to their maximal potential.
PSYCHOSOMATIC GASTROINTESTINAL DISORDERS
Numerous investigations20 indicate that psychic influences can produce spasms in the gastrointestinal tract. Inability to recognize and treat these influences accounts for failures in many patients with gastrointestinal dysfunctions. The combination of hypnotherapy with a medical regimen in properly prepared patients readily offsets noxious cortical influences, and thus ameliorates the disordered mood and resultant disturbed motility.
The imagination plays an important role in digestive upsets; for instance, merely hearing a description of a nauseating smell or even thinking about swallowing castor oil can induce vomiting in highly susceptible persons. Radiographically, it has been demonstrated that gastric activity of the stomach can be varied with emotional affects.70 Physiologic correlates of emotions also have been induced by hypnotic conditioning. In all probability, such emotions exert their influence on the gastrointestinal tract by a combination of hormonal and neural routes which act reciprocally with a local tissue vulnerability to result in functional symptomatology.
Emotional influences are transmitted to the gastrointestinal tract by way of the anterior hypothalamus and the vagus nerves. Another route is by way of the posterior hypothalamus and the pituitaryadrenal axis. The cortex not only actively participates in all visceral and autonomic activity, but also maintains equilibrium between the parasympathetic and the sympathetic systems.
The more common gastrointestinal disorders with a large emotional overlay that are amenable to hypnorelaxation are peptic ulcer, spasms of the bowel, gastritis and duodenitis, mucous colitis, diarrhea, pylorospasm, spastic constipation, and biliary dyskinesia. Other associated conditions are glossitis and bizarre tastes in the oral cavity, globus, dysphagia, cardiospasm, dyspepsia, aerophagia, anorexia, ptyalism, nausea and vomiting, pyrosis, bloating, and flatulence; all of these have a high content of severe anxiety.
Patients with such symptoms usually state, “I have always had a nervous stomach.” Repeated physical examinations seldom reveal the cause of their difficulties. Many have had some type of abdominal surgery, a long history of digestive upsets and/or food intolerance, as well as severe symptoms of chronic anxiety and tension.
Since vacations, hospitalization, and removing the patient from his family or business worries often bring about a sharp reduction in symptoms, psychic factors obviously play an important role. In addition to medication and dietary measures, hypnotherapy directed toward relaxation and correction of faulty behavior patterns is often successful. Reassuring the patient that an organic involvement does not exist improves gastric function in many chronic dyspeptics.
Refractory individuals generally require hypnotherapeutic measures directed toward a reduction of their anxieties and tensions, and then a discussion of their problems, such as that described below under peptic ulcer.
Peptic Ulcer
It has been well established that peptic ulcers occur following severe burns, shock, and anoxemia—thus stimuli mediated via the cortex and reticular formation apparently excite the adrenals, and the resultant corticotropin output increases the activity of the parietal cells in the stomach. Other diverse factors such as heredity, age, conditioning by previous exposure to stress, and the nutritional state can affect both the production of the adrenal hormones and their feedbacks to the higher centers, and thus affect the gastric mucosa.
Before instituting therapy, a careful history and physical examination should be made. Several multievaluation sessions are required to select patients for hypnotherapy. Initially, therapy should elicit the relationship between the character of the emotional upsets and the symptoms. If the patient is seen during an attack, questioning should be directed to the type of mood, thoughts, or environmental stimuli that preceded the onset of the symptom. In good hypnotic subjects, one can “trigger” the symptoms by suggesting specific situations or thoughts that obviously are etiologic. In this manner, the subject obtains a clearer understanding of the manner in which stressful stimuli exacerbate and maintain the chronicity of the symptom.
It is helpful initially to tell the patient: “There are persons who can get rid of their angry feelings and promptly forget about it. Others cannot do this and develop a great deal of aggravation and they get terribly upset. No wonder that their stomachs act up.” The patient can be motivated for hypnosis by being asked, “How would you like to learn not only how to control your nerves, but to relieve your stomach symptoms?”
The patient is asked to identify and enumerate those emotional situations connected with his symptoms in order of their importance. Under hypnosis, reciprocal inhibition technics described in Chapter 50are used to “immunize” him against their harmful influences. He is asked to think and discuss the least aggravating conditions first and the more serious ones later. He is also advised that while under autohypnosis he can use self-exploration to assay his needs for the symptom. Then a constructive plan that will enable him to meet his future needs without frustration, anxiety and tension is discussed with him. Also, posthypnotic suggestions to associate pleasurable reactions with partaking of foods that were formerly upsetting is helpful.
Since most ulcer patients crave love and affection in the form of recognition, hypnotherapy must be directed toward building up these strong emotional needs. After these, as well as those necessary for healthy functioning of the personality have been dealt with, the patient can be made relatively independent of the operator by training him in autohypnosis and sensory-imagery conditioning. Moody,60 using controls, noted improvement in 20 patients treated only by directive hypnosuggestive procedures. The successful therapy of an ulcer patient by hypnosis has been described.59
Hypnosis in the form of prolonged “sleep” is excellent for some refractory ulcer patients. Wennerstrand, the great Swedish hypnotherapist, kept his patients almost continuously under hypnosis for several weeks. Andreev recently described how prolonged hypnotic “sleep” is more conducive to relaxation than is continuous intravenous Amytal.2 The only disadvantage is that a trained person has to be in constant attendance. The patient is dehypnotized only for evacuation and feeding. In this way, the organism is maintained at complete physiologic rest. Stress is eliminated, and the ulcer has a good chance to heal. Long-term follow-up psychotherapy is necessary to prevent relapses.
The rapid mobilization of faith and confidence by hypnosis, together with the establishment of healthy emotional attitudes, and the meeting of his needs—all play an important role in facilitating recovery. Most ulcer patients will respond to relaxation, reassurance, reeducation and hypnosuggestions for symptom removal when this approach is incorporated with a medical regimen. Those who cannot be helped by any type of psychotherapy require environmental manipulation, change of occupation, hospitalization and/or surgery.
Colitis
Emotional maladjustments are closely related to colitis. Fear and tension usually aggravate such bowel symptoms as pain, diarrhea, bloating, and bleeding. These are often associated with depression, migraine-like headaches, irritability, and anorexia. Most sufferers with colitis have fears and unresolved anxieties; they are characteristically referred to as “having no guts.” The bowel, for reasons unknown, becomes the target organ for displacement of unexpressed anxieties and tensions.
Hypnorelaxation, with strong posthypnotic suggestions involving reassurance, helps some colitis sufferers face their conflicts; these generally involve social and occupational maladjustments. However, the majority respond poorly to hypnotic conditioning as well as to other psychotherapeutic procedures. They usually improve on any regimen, but relapse rapidly. The ideal approach consists of permissive hypnotic technics, sensory imagery, autohypnosis, a dietary regimen, and tranquilizing agents. Surgery should be recommended for unresponsive patients.
Ulcerative Colitis
Nearly all investigators agree that psychogenic factors play an important role in the cause and the maintenance of ulcerative colitis, especially with reference to the exacerbations of the symptoms.
The physical aspects of the disease are serious and should not be neglected. Here, too, as in the colitis sufferer, one must find out how and why the patient reacts to his deep-seated emotional problems with his gut. A combined medical and psychological approach is always indicated. Hypnotherapy includes sympathetic understanding of the patient's plight, strong reassurance, even stronger persuasion and encouragement, and a thorough discussion of the patient's problems. Many of these patients feel that their prognosis is hopeless, so the major objective is continually to reinforce their confidence and outlook toward life. They deteriorate rapidly unless intensive psychotherapy is instituted. Without controls, it is difficult to determine how much these patients are helped by any type of psychotherapy. A few have been arrested, probably temporarily. Others go rapidly downhill and require successive resections of the bowel. On the surface, these individuals wish to live, but the majority have unrealized death wishes. Many are caught in marital or occupational “traps.” As a group they are easily frustrated, ambitious, and compulsive.
Emotional Diarrhea
Nervous or emotional diarrhea responds to hypnotherapy. It generally occurs in sensitive and unstable persons. Episodes usually follow stress, tension, and anxiety. The urge to defecate immediately after eating or drinking suggests a triggerlike gastrocolic reflex mediated by cortical and subcortical centers.
In addition to dietary and medical measures, hypnorelaxation is particularly beneficial in mild cases when it is combined with direct suggestions, anticholinergic drugs, and tranquilizers. Those refractory to this approach require correction of the autonomic imbalance. This is best achieved by supportive psychotherapy under hypnosis. Many of these individuals already have had deep probing of their personalities without affecting the chronicity of the symptom. Often refractory cases respond to intensive hypnotherapy when directed toward enabling the patient to face his problems.
Postgastrectomy Syndrome
Following subtotal gastrectomy, some patients develop the dumping syndrome, consisting of anorexia, nausea, vomiting, vertigo, sweating, fatigue, and weight loss. Often these symptoms become chronic, especially if associated with anxiety and tension. Cases have been treated successfully by hypnoanalysis.71
Dorcus and Goodwin treated a small series of cases by direct posthypnotic suggestions centered on reducing tension, removing fear of the symptoms, and improving the olfactory appeal and consumption of the food itself.19 Despite the fact that only direct symptom removal was used, not a single case relapsed. In another study on nutritional problems, directive hypnotic technics increased caloric intake, relieved certain food restrictions, allayed pain and helped remove the accompanying loss of appetite.24
Good results have been attained by group hypnotherapy.53 The author treated several cases by sensory-imagery conditioning. Posthypnotic suggestions associated with pleasant memories, involving the sight, the taste, and the smell of all the foods which the patient enjoyed before his surgery, were utilized. Glove anesthesia, transferred to the epigastrium, relieved the nausea and the vomiting in susceptible patients.
Constipation
Obstinate constipation that does not respond to laxatives can be helped by posthypnotic suggestions and sensory-imagery conditioning. One cannot merely suggest under hypnosis that the patient will have a bowel movement at a certain time but, rather, that all the subjective sensations associated with a normal evacuation will be experienced; these are “rehearsed” during autohypnosis.
The rectal sphincter is under autonomic as well as volitional control, which provides this area with a “time sense.” One usually develops the desire for defecation as the result of a well-established habit pattern. When this pattern is disturbed, constipation often results. Patients are first trained in hypnosis and autohypnosis. Then, during a self-induced hypnotic state, the patient describes in minute detail what a normal evacuation feels like to him. All relevant details such as the time and the nature of the “call to stool” signal, and the type of spasms or tenesmus at the rectal sphincter are elicited. It is now suggested that all these sensations will be experienced during the next few days. The exact time can be suggested.
Biliary Dyskinesia
Dysfunction of the gallbladder may result from disturbances of the sphincter mechanism that is regulated in part by autonomic impulses, or from functional derangements in other portions of the biliary tract. Symptoms arising from a normally functioning gallbladder without stones frequently indicate a psychosomatic involvement. Emotional factors often can upset the function of the biliary tract.
After reviewing the literature, Ivy concluded that the choledochoduodenal mechanism can contract with sufficient force to prevent the evacuation of the contracting gallbladder and to counteract the secretory pressure of bile.38 An increase of intracholedochal pressure has been associated with intense emotional stress. Such a rise may be due to hypertonus of the duodenal sphincter. There is also a physiologic basis for emotional jaundice. A syndrome has been described, consisting of distention of the gallbladder secondary to spasms of the sphincter of Oddi. The contractions are mediated by vagal impulses of central origin, with symptoms of biliary colic and even jaundice. The syndrome has responded to environmental manipulation, psychotherapy, and some monoamine oxidase inhibitors.
Surgeons are aware that some patients with prolonged icterus, intense pruritus, negative parenchymal tests, and normal structures at laparotomy, promptly establish bile flow with relief of itching on drainage of the ducts. This must be a functional jaundice. Even if calculi are present in the bile ducts, this does not necessarily rule out the possibility of emotional factors.
Derangement in cortical dynamics, acting through limbic system activity, can trigger spasms of the duodenum and of the sphincter of Oddi. Either of these can produce distention of the gallbladder, colic, and jaundice, and the resultant stasis can contribute to stone formation. This author has seen a Yoga who under fluoroscopy could voluntarily contract the duodenal sphincter. Thus far there are no reports of emotional icterus or biliary dyskinesia treated by hypnosis. However, the syndrome has responded to change of environment, mental rest and sedation.
Glove anesthesia and opiates are the methods of choice for short-term relief of pain. In the presence of intermittent substernal pain, further search for such physical factors as reflex coronary spasm should be made.
Summary
Psychosomatic gastrointestinal disorders are, in part, produced by emotional factors and visceral reactions to physical stressors. Therefore, an interdisciplinary therapeutic program directed toward the psychic and the somatic factors is indicated. Hypnotherapy, judiciously employed in selected patients, can potentiate the medical therapy of gastrointestinal complaints caused or aggravated by emotional stress.
Hypnotherapy, as described, has proved to be beneficial in many patients who were unable to respond to a wide variety of medical measures. This approach has afforded considerable relief of pain, spasms and other related disorders such as heartburn, nausea, pylorospasm, eructations, and other symptoms. Sensory-imagery conditioning and glove anesthesia are valuable adjunctive procedures.
Hypnosis relaxes many anxious and disturbed patients, reduces their tension, helps relieve the irritability caused by a strict dietary program, and also increases the likelihood of cooperation with the medical regimen. The dual approach provides the physician trained in hypnotherapy with a comprehensive and definitive therapy for conditions many of which are refractory to general psychotherapy.
It is unfortunate that some of our cases could not be followed and that space does not permit a fuller description of the nuances of the interpersonal relationship which in any form of psychotherapy affords a bulwark of support to the emotionally disturbed patient. The reader should not get the impression that all our cases were helped or cured. We have failures and these are discussed in Chapter 52. In this book, we are presenting primarily our successful cases, realizing full well that a placebo effect exists in every psychotherapeutic relationship, including hypnosis!
OTHER PSYCHOSOMATIC DISORDERS
Tuberculosis
Tuberculosis is, in part, a disease of maladaptation due to stress.76 The importance of the psychologist and the psychiatrist in the therapeutic program is incalculable. Correction of human factors which defeat the ministrations of the physician is mandatory in this disease. Almost half the patients institutionalized do not take their medications, refuse surgical treatment, or leave the hospital before being discharged as cured.
It is believed that adrenocortical activity plays a role in resistance to tuberculosis and that the effects of stress on the course of the disease may be mediated in part by the adrenals.36
The relevance of personality factors to the cause of tuberculosis has been described by many investigators.20 Many patients are insecure, rebellious, overassertive, hard-driving, and conflict-harassed individuals. Thus, at present, the research is directed more toward the host than the bacteria. The combination of psychotherapy, energetic drug therapy, and well-timed surgery can increase the cure rate in chronic tuberculosis. With reference to surgery, the need for an adequate personality study in all patients requiring thoracoplasty has been stressed. Preoperative hypnosis can be useful in raising the threshold to shock, especially in debilitated patients or in those who have a “will to die.”
Hypnosis can facilitate relaxation and feelings of well-being in subjects who require complete bed rest for months.1 It can also be employed to stimulate the appetite, promote sleep and rest, and change the patient's unhealthy attitudes.
The author has had very little personal experience with hypnotherapy in tuberculosis, but believes that this area affords another promising area for research. Osler once advised that when a physician sees a patient with tuberculosis, he should not treat his chest, but rather his head. The reader interested in one of the best interdisciplinary studies made on tuberculosis should read Personality, Stress and Tuberculosis.76 The resigned attitudes of consumptives to the disease itself must be taken into consideration.
Hypnosis has been used individually and by group therapy for tuberculars in the Soviet Union to alter the patient's outlook toward his misfortune and to inculcate cheerfulness and confidence in his recovery. Specific posthypnotic suggestions are: “You will eat everything with relish because your full recovery depends on it, especially butter, milk and rich food. Recollection of your difficulties no longer troubles you as you will maintain your interest in life.” Such encouragement can invariably stimulate the adaptive processes and help the tuberculosis patient in the successful struggle against his disease.
Migraine Headache
Etiology
Although the precise mechanisms responsible for migraine headache have not as yet been elucidated, there seems to be little doubt that emotional tensions are precipitating factors in most instances. Likewise, the existence of a “migraine personality” cannot be satisfactorily substantiated even though many migraine sufferers are compulsive, rigid, hostile, and perfectionistic.
Many causes have been suggested, such as vasoconstriction, vasodilatation of blood vessels, leading to a combination of distention and altered sensitivity which results in pain,67,68 heredity and allergy.82Miscellaneous factors that have been suggested are electrolyte imbalance, histamine sensitivity, elevated serotonin levels,67 anoxia, vitamin and hormonal deficiencies, ocular malfunctions, and chronic intestinal disorders.27
The author wishes to advance a speculative hypothesis for the currently accepted vascular basis for migraine headache. He postulates that, when we once walked on all fours, the head or cephalad portion of the body was functionally significant, especially for feeling states involving fight and rage reactions (head lowered to charge at an opponent). During our evolutionary development, the somatic manifestations of emotions involving rage continued to be displaced cephalad. Thus this deeply repressed response may occur as an atavism in those unable to express rage. In such predisposed individuals, the blood rushes to the head, with chronic vasodilatation and subsequent vasoconstriction. The blood vessels become hard, tender, and rigid, and this produces a steady ache accompanied by spasm and pain of the neck muscles.
Treatment
The possibility of such physical factors as brain tumor, sinusitis and other organic conditions must be ruled out before instituting any type of therapy. The psychogenic factors involved in tension headache or migraine respond readily to hypnotherapy, particularly cluster headaches (atypical facial neuralgia). There are numerous reports on this approach.1,3,4,16,29,31,34,37,46,71,84 The author has utilized directive hypnotherapy for menstrual migraine and for headaches associated with premenstrual tension. The literature on hypnosis and behavior modification has been fully described by Kroger and Fezler.50
The purpose of all treatment is to relieve tension and raise the pain threshold. Should analgesics or local methods of therapy fail, hypnosis is the method of choice, especially if it is combined with autohypnosis and glove anesthesia.
The generalist who is familiar with hypnotic technics is in an enviable position for treating such individuals, as he knows the longitudinal life history of his patients and has already established a good rapport. Rarely is formalized depth psychotherapy indicated in resistant cases of migraine, as the results are about the same as with directive hypnotherapy, which is less time-consuming and less expensive.
Hypnotic relaxation, supportive psychotherapy, education, and adjunctive pharmacotherapy can reduce the frequency and the intensity of tension headaches, especially if the patient is enabled to understand how he is reacting to his life situations and what he can do about facing his problems with more equanimity.
Many drugs recommended for migraine headache have little more than a placebo effect. Friedman states:
In treatment of headache it is well to remember that the efficiency of any drug depends upon many factors. The emotional factors influencing results of treatment depend upon the personality of the patient, the method in which the medicine is applied and the doctor-patient relationship. The personal influence of the physician is most important.27
Ostfeld sums up the current attitude toward therapy by stating, “Two out of three patients with migraine can be greatly helped by any physician who is interested in human problems and is willing to spend a minimum of time with a patient in reviewing them with him.”67
Cedercreutz and co-workers utilized directive hypnotherapy in 155 skull-injured patients.7 Posttraumatic headache and vertigo were completely relieved, after an average observation period of 22 months, in 50 to 58 per cent of the patients, and partially relieved in 20 per cent and 16 per cent respectively.
ARTHRITIS AND RHEUMATISM
There is a large body of literature on the psychosomatic factors in arthritis and rheumatism. A high percentage of patients who complain of pain have minimal radiologic findings; contrarily, those who show extensive damage often have little discomfort. Most drugs and procedures employed to treat these conditions have little more than a placebo effect.80 Data indicate that aspirin and salicylates are as good as steroid medication even in rheumatoid arthritis. Hypnotic suggestion is often effective for symptom-relief and dramatically relieves the distress in the milder attacks. Hypnosis is of little value in osteoarthritis.
Pain can be controlled by the production of glove anesthesia and sensory-imagery conditioning; these reduce narcotics, steroids and analgesic drugs. Hypnosis should always be directed toward relaxing the musculoskeletal “armoring” which characterizes many arthritics. Even at rest, their muscles are in a continual state of spasm. Autohypnosis to promote relaxation and mobility of joints can be most effective. Dissipating the discharge of strong emotions which maintain chronic muscular tension often can prevent an attack.
Even strong suggestion per se can help many chronic arthritis sufferers, especially those who have a large psychogenic component to their ailment. Shrines and faith healers cure many such individuals. The value of spa therapy is due to the relaxation produced by separation from adverse environmental factors plus a nonspecific placebo effect.
The author has had gratifying success in ameliorating discomfort in small groups of arthritics by merely teaching the patients glove anesthesia and how to relax by autohypnosis. Contributory conditions such as overweight and dietary indiscretions are controlled by appropriate hypnotic suggestions.
Raginsky points out that attacks of arthritis can be either relieved or reinduced through hypnosis when the proper stimulus is applied.71 He states:
The emotional stimulus appeared to be almost specific for the individual so that he would become embroiled in a conflict which resulted in symptom formation. What is of interest here is that once the attack of rheumatism or gout developed in these patients, the attack could be shortened immeasurably through hypnotherapy.
It must be emphasized that arthritis is a disease of unknown etiology with protean manifestations involving all systems of the body. The spontaneous remissions and unexplained exacerbations which characterize the course of the disease make it difficult to evaluate critically the results of hypnotherapeutic management of this condition.
HYPNOTHERAPY IN METABOLIC DISEASES
Diabetes Mellitus
The emotional factors in diabetes were recognized in the seventeenth century when Thomas Willis, describing the sweet taste of diabetic urine, said that the disease was due to “prolonged sorrow.” Recently, an extensive literature has pointed out that the effects of stressful life situations are a contributing cause of diabetes.20,35
The relationship to diabetes of fear and other psychic factors in anxiety has long been recognized by numerous investigators. These may interfere with therapy or indirectly affect the disease. Thus emotional stimuli originating in the cortex affect the hypothalamus via the limbic system. As a result, overstimulation of the adrenals causes impairment of glucose tolerance, increased insulin resistance, and sometimes ketosis. The concept of islet cell deficiency of the pancreas as an etiological factor is no longer valid. Heredity, obesity, hormonal dysfunction, and genetics play an important role. Hyperglycemia might be compared to an alteration in hemoglobin—both are symptoms. Emotional factors can precipitate hyperglycemia, particularly in the presence of sustained conflict.
Hypnotherapy can be directed toward a reduction of the stress component by achieving relaxation. Also, it can be helpful indirectly by maintaining weight reduction in obese individuals. Posthypnotic suggestions or autosuggestions enable poorly motivated persons to limit their dietary intake to prescribed foods.
Much more can be done for the diabetic than just keeping his urine sugar-free by means of diet and insulin. An appreciation of the patient's personality makeup, his strivings and frustrations, his home environment and relationships as well as recognition of how to cope with current stresses, allows a wider scope for the physician in the treatment of this condition. In selected cases, the use of hypnotherapy can reduce the quantity of insulin needed to keep the urine sugar-free and also can reduce the frequency of the attacks of ketosis.
The author remembers several patients whose diabetes improved after emotional adjustments to domestic and sexual difficulties had been made. In one, a 42-year-old male who developed impotency, hypnotherapy directed toward this condition modified the course of the disease. In another, a very sick diabetic, drastic weight reduction through hypnosis alleviated the disease. In still another, reestablishment of potency materially reduced the need for insulin.
In general, hypnotherapy finds its greatest utility in the treatment of the psychic factors contributing to the diabetes. From recent experimental evidence there are strong indications that diabetes is not limited to being a dysfunction of carbohydrate metabolism, but rather is a multifaceted disease. For instance, some patients are diabetics but have normal fasting blood sugar levels and their urine examinations consistently are aglycosuric. Hence, insulin deficiency need not be the only factor involved in the production of lesions characteristic of diabetes. It is logical to postulate from this that unknown endocrine or metabolic processes secondary to corticohypothalamic dysfunctions may be implicated. It is in such cases that attention to the psyche by hypnosuggestive procedures is indicated.
Particularly germane to this discussion is the influence of the cortex on carbohydrate metabolism studied under hypnosis. When a hypnotized subject is given a concentrated solution of sugar, and is told it is distilled water, the blood sugar does not increase but may sharply diminish. Obviously, under the influence of suggestions at the verbal level, a strong unconditioned stimulus loses its force or provokes an unusually distorted action. This paradoxical phenomenon is well known among Pavlovians and may be the “unknown factor” accounting for unrecognized diabetes as well as explaining the results obtained by hypnosis. Foa described how the mediation of psychic stimuli and regulation of endocrine function resulted in diabetes.23
OBESITY
Overweight is one of the common problems that are brought to the physician's attention. It accounts for a high percentage of degenerative diseases; therefore, its treatment by hypnosis will be discussed in detail. Numerous authors have discussed the importance of psychic factors in stimulating the drive to eat. This is particularly pronounced during the evening, and has been referred to as the “night-eating” syndrome.
Psychological Factors
It has been demonstrated that, in addition to the deeper psychological forces at work, the ordinary vicissitudes of daily living contribute to the desire to overeat and to the inability to diet. Thus domestic upsets, fatigue, sexual problems, economic worries, and many other such common sources of tension interfere with the reduction of food intake. The treatment of overweight is much easier if tensions are eliminated. It has been noted that most of the patients who feel well as a result of reduced tension and frustration achieve successful weight reduction.25 Only those who are emotionally stable should undertake a drastic reducing regimen.5
As has been mentioned, tension and frustration often lead to excessive caloric intake and subsequent obesity. These reactions usually depend on early developmental patterns. For example, the hungry infant soon learns that frustration is relieved by the pleasurable experience of nursing, thumb-sucking, or playing with a rattle. Although these earlier tension-relieving mechanisms are repressed, the individual always “remembers” the route by which gratification was once afforded.
Other oral methods for the relief of tension are chain-smoking, chewing gum, and nailbiting. Insecure adults, when faced with frustration, resort to one or more of these tension-allaying outlets. This “return-to-the-breast” mechanism now involves the use of food to satisfy the oral cravings, since the bottle, the nipple and the thumb are no longer acceptable. Contrarily, many individuals lose weight following stress.
Excessive food intake can also result from other causes. For instance, in certain “food addicts,” overeating is often a substitute for suppressed hostile impulses. Since they cannot express anger toward those around them, they take it out on food, which is smashed to pieces. In homes where food is hard to get, the children eat everything available today, for tomorrow there may be no food. Many parents warn against wasting food, and also praise their children for being good eaters. Even after becoming wealthy, such individuals must “always clean the plate.” Parental attitudes and other psychosocial factors determine one's eating habits. Thus a child brought up on large, rich meals usually imitates the parents' eating habits. This tendency is more often responsible for obesity than hereditary factors.
Overeating due to tension may follow the death of a friend or a relative. Frequently, food is used as a substitute for love. For example, people who are alone and who feel unwanted and unloved, substitute the pleasure of eating for affection. Their attitude is: As long as no one loves me, I will be good to myself. Unwanted children often become obese. To relieve their guilt feelings, some mothers become overprotective and stuff the children with food as a proof of their “love.” Then, being concerned about their children's weight, they seek the physician's help. They refuse psychotherapy, however, because of their own emotional problems.
Adult obesity is a sign of social prestige and a “badge of wealth” in many cultures, in which a child is overfed to make it fat, not only because “big babies are healthy babies,” but also because a plump baby is highly esteemed.
An occupation sometimes is the primary cause of obesity. In high-strung individuals such as actors, singers, or executives, eating may be used for relaxation. Conversely, people who lead a dull life eat more often than usual to relieve the monotony. This is commonly noted in housewives who “raid the icebox” between meals to lessen the drudgery of their work. There are many women who remain obese because their spouses prefer them fat. Since these husbands may have an inferiority complex, they feel more secure with plump wives, who are considered less attractive in a “thin-oriented” society such as our own. Sterile women often use obesity as a symbol of the wish for pregnancy.
Persons with heightened sexual impulses often displace these drives by food intake and eat ravenously. Sooner or later this type of individual reacts toward eating with the same feelings as he or she had about sex—namely, shame, guilt, and anxiety—and then more food is required to alleviate the tension. Many emotionally insecure individuals unconsciously believe that a heavy layer of body fat is a protective armor against a hostile world. For instance, the young girl, guilty over her sex drives, often retreats behind the “wall of obesity.” By doing this, she now has a readymade alibi for not being attractive to men. She can safely say, “I am so fat, no wonder boys are not interested in me.”
Many young athletes enjoy eating large quantities of good food, but they do not gain weight when they are physically active. As they grow older and their lives become more sedentary, their caloric intake exceeds their energy requirements, yet their level of satiation is raised because of their previous eating habits. This type loses weight with difficulty.
The rationalizations proffered for overeating are many. Some of these are: It runs in my family; it's my glands; others eat twice as much as I do. However, the actual causal factors are hostility, anxiety, guilt, self-pity, self-punishment and depression. These are usually found in combination and are often repressed from awareness.
Obviously, with psychological factors so frequently at the root of obesity, the difficulties of weight reduction cannot be overcome on the level of general practice unless pharmacologic agents can provide powerful assistance. Amphetamines are the most effective appetite depressants in current use. The action of the amphetamines can be negated by severe emotional tension, premenstrual tension, untreated menopause, impotency, and other symptoms.
In addition to those resistant to medication, there are the paradoxical reactors who require much larger doses of sedatives, amphetamines and other drugs than the average person to achieve any type of pharmacologic response. In these individuals, one can use hypnotherapy as an adjunctive procedure.
The preliminary discussion is usually conducted after the physical examination and before the induction of hypnosis. It is as follows: “Our approach is a threefold one. First, it is axiomatic that you cannot lose weight unless you take in fewer calories—this means that you will have to follow a diet. All diets are good, but they are only as good as the way they are followed. You will be helped to avoid fattening foods through various hypnotic technics. Please be assured that you will not be hungry and that you will be able to eat an adequate amount of nutritious and healthful foods. Diets, as you know, can actually refer to eating more food, but of the right type.
“The second approach consists of medication. However, all types of medications, as appetitesuppressing drugs, have their limitations. They are useful, nevertheless, until proficiency has been developed in following the posthypnotic suggestions. They are particularly advantageous to get you started and motivate you to continue with other procedures. In addition, drugs will help overcome many depressive feelings that cause you to overeat. These drugs seldom produce nervousness, sleeplessness and palpitation of the heart. If you should by any possibility develop any one of these reactions, report to me at once and you will be given other medications.
“The third or hypnotherapeutic portion of the treatment consists of training in hypnosis and autohypnosis, wherein you will give yourself appropriate autosuggestions. The degree of success will be in direct proportion to the amount of effort you put forth in the practice sessions. If you practice autohypnosis faithfully, you can expect better results. You additionally will be helped to understand what your need to overeat represents. You will also be taught how you can face your problems on a more adult level instead of putting food in your mouth to allay anxiety-provoking tensions in the same manner you once used a rattle, a nipple, or a bottle.”
The verbalization after hypnotization that has been found applicable to most patients is: “If you really wish to lose weight, you will roll the food from the front of the tongue to the back of the tongue and from side to side in order to obtain the last ounce of satisfaction and the ‘most mileage’ out of each morsel and each drop that you eat. By doing this you will more readily satisfy the thousands of taste cells that are located all over your tongue (there is an appetite center located in the hypothalamus), and, as a result, less food will be required and your caloric intake will be immeasurably curtailed.
“Secondly, you will ‘think thin,’ that is, you will keep an image uppermost in your mind of how you once looked when you were thin. Perhaps you have a picture of yourself when you weighed less. If so, place this in a prominent position so that you will be continually reminded of the way you once looked. There is considerable basis for this suggestion. You undoubtedly are aware that if a woman imagines or thinks that she is pregnant, her body will develop the contour of a pregnant woman; her breasts will enlarge and she may, in many instances, stop menstruating. Also, you may have at one time experienced a great deal of inner turmoil and lost weight in spite of the fact that you ate excessively. Cannot a frustrated lover also ‘pine away’ for the beloved?
“Thirdly, you might like to think of the most horrible, nauseating, and repugnant smell that you have ever experienced. Perhaps it might be the vile odor of rotten eggs. In the future, whenever you desire to eat something that is not on your diet, you will immediately associate this disagreeable smell with it. Also, you might like to think of the most awful and disgusting taste that you may have had in the past. This, too, can be linked up with fattening foods even when you merely think of them.
“Finally, for this session, remember that you cannot will yourself to lose weight. The harder you try, the less chance you have to accomplish your aims. So relax—don't press. The imagination determines this struggle, so would you mind purchasing the most beautiful dress that you can afford? Hang it up in your bedroom where you can see it every morning and imagine yourself getting into it within a relatively short time. You can speculate how soon this will be. Now this is important! The dress that you buy should be at least one or two sizes too small for you.”
The suggestions above are given after the operator is certain that hypnosis has been induced. Following dehypnotization, the rationale for these suggestions may be discussed if the patient is inquisitive about them: “There is no question that there is a close association between the thousands of taste buds and the impressions that they convey to the higher brain centers for interpretation.”
The “think thin” suggestion makes use to a degree of the alteration in body image secondary to strong emotional stimuli. It is well recognized that emotions can alter metabolic and endocrine activities to produce weight gain. This has been illustrated vividly in phantom pregnancy or pseudocyesis. If the autonomic nervous system can “trick” endocrine activities and bodily processes into responding with a weight gain to expressed or unexpressed wishes regarding pregnancy, then it is conceivable that these same pathways can produce loss of weight.
The association of fattening foods with disagreeable tastes and odors to produce an aversion is based on classic conditioning methods. While the organs of taste and smell are distinct, the impulses from each reach the cortex by different pathways. However, the two senses are closely associated psychophysiologically. They should be designated as chemical senses because chemical rather than physical stimuli act on the receptors in the higher centers. The most important aspect of flavor is due to the sense of smell rather than of taste. Olfaction is sensitive to small changes because it is capable of ascertaining the location of the source. In addition to these chemical sensations, smoothness and roughness, temperature, and pressure sensations originating in the mouth contribute to taste impressions.
Some attempts have been made to explain how various tastes can give rise to nerve impulses, but there is still insufficient knowledge to formulate a working hypothesis. However, in man the sense of smell remains closely associated with the motivation of the individual to eat. As described in Chapter 32, the close association of the limbic system (cortical areas, nuclei, and fiber tracts phylogenetically associated with the sense of smell) with the emotions is now generally accepted. Perhaps no sense is more provocative of moods and memories than that of smell, and so the smell of food may enhance or diminish the appetite. The close association of taste and smell with feeling states is further reflected in the words that we use to express our reactions to things—we speak of a “sweet” girl, a “salty” character, and “sour” grapes. In particular, we use the idea of “taste” to express our feelings.
The fourth suggestion has a twofold meaning. First, it is highly motivating, as it stresses the value of a nice figure by indirection or extraverbal suggestions. This approach does not mobilize a critical attitude. It makes full use of the imagination. One must be careful to suggest that not all these affirmations or aids will be utilized immediately, but that continual repetition through autohypnosis eventually will enable the overweight person to respond to these autosuggestions.
If the subject has had some modicum of success, the following verbalization is used on subsequent visits: “You will, if you really wish to lose more weight, consider the following suggestions: Do not plan on more than a 6- to 8-pound weight loss per month, but set a deadline for this weight loss. You will try harder when you have to meet a deadline. Wonder whether you will reach your objective before or after the deadline date.
“The desire to eat results when the appetite center in the brain is stimulated, whereas hunger is brought on by contractions of the stomach. If you wish temporarily to delay eating your next meal for several hours, all you have to do is to employ glove anesthesia over the pit of the stomach in order to “knock out” the hunger contractions which are initiated in this area. Another suggestion that might appeal to you, especially if you are interested in having a trim figure, is to think of your ultimate goal in terms of the actual weight desired. Let us assume, for instance, that you would like to get down to 130. This will be what I call a ‘food stamp’ suggestion, that is, every time you even think of eating something you are not supposed to, you will see the number 130 in blue encircled by a blue ring, much as the price of an item is stamped on the food can in a grocery store. You will give yourself this suggestion particularly at night if you get extremely hungry before retiring.
“Finally, if you find that you have exceeded the required food intake and you are still hungry, you can place yourself in hypnosis and imagine that you are eating enough pleasurable food to satisfy yourself.”
During future visits the patient is asked to repeat the affirmations until they are remembered, and also for purposes of reinforcement. New suggestions to reduce caloric intake can be incorporated with the old. These consist of strengthening the patient's desire for weight loss by stressing the health, the social and the beneficial appearance of a trim figure; these act to reinforce the patient's own specific reasons for losing weight. Posthypnotic suggestions may be given to eliminate “eating between meals,” “nibbling,” and munching on such items as peanuts while watching television. For those who have a full social life, suggestions can be given to resist inordinate demands for eating and drinking. Suggestions for a specific type of diet, such as one high in protein but low in fats, carbohydrates, sodium, and liquids, may be employed at hypnotic levels. Likewise, suggestions at hypnotic levels may be given to induce proper alimentary functions.
Some of the above suggestions have a psychophysiologic basis. There are hypothalmic centers mediating hunger and satiety. They not only have separate anatomic locations but also different behavioral consequences. Appropriate lesions made in these brain areas in experimental animals result in bulimia, and they eat ravenously. Recent clinical studies suggest that either a decreased satiability or an increased hunger drive accounts for obesity.25
It has been established that one of the principal physiologic centers for initiating hunger contractions is just below the xiphoid process in the region of the epigastrium. Many obese individuals are not hungry but eat because the hunger contractions are conditioned to a time schedule. It is recognized that following the old adage, “Tighten up your belt a notch,” can assuage hunger.
The deadline suggestion is obviously only to increase further motivation. This applies also to the “food-stamp” suggestion. Many of the other suggestions are based upon the correlation between taste and the visual senses being stimulated. Visual senses develop appetite at the expense of taste and smell. The tongue and the connecting brain centers are continually stimulated by the reciprocal feedback connections. No wonder one unidentified wit observed, “One tongue may have three times as many taste buds as another and the empire of taste also has its blind men and deaf mutes.”
Hypnoanalytic technics are generally required (Chap. 50) to discover the basis of the patient's need to overeat (Chap. 50). A strong rapport, a noncondemnatory attitude, and encouragement when failure occurs facilitate psychotherapy. When permissive technics are employed and it is emphasized that it is a “do-it-yourself program,” undue dependency is avoided. Furthermore, as described above, hypnotherapy is used as part of a total approach consisting of a sensible diet and appropriate medications.
Other investigators have used hypnosis for obesity with varied success.8,65,66,77,81,83 It has been employed in a psychodynamic behavior modification model emphasizing the holistic approach.43,49 Tilker and Meyer have combined hypnosis and aversive conditioning.79 Wick and co-workers used the constructs of hypnosis without hypnotic induction.83 Crasilneck and Hall discuss hypnotic management of obesity and dietary problems in detail.14 It has been noted that one group paying a fee got better results than a control group which did not pay. Both groups were hypnotized.77
Group hypnosis for obesity is even more rewarding than individual sessions.32 The same factors apply as those described in group training for childbirth. The author sees four to five patients for 1 hour, at first weekly and then biweekly. After the patients have learned autohypnosis and how to modify their eating habits, medication is discontinued. The use of psychotherapy is helpful in maintaining the optimal weight after it is reached. About 40 per cent of patients relapse and require periodic reinforcement to prevent further weight gain.
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HYPERTHYROIDISM
Stress plays an important role in altering thyroid function. Overelaboration of the thyroid-stimulating hormone (TSH) is often secondary to cortical-hypothalamic factors. Though the causes of this condition are multiple, emotional factors can modify thyroid function. Nearly all patients are easily upset, sensitive to their environments, and exceedingly intolerant. Hypnotherapy must be directed toward a reorganization of personality functioning. Not only can it implement medical therapy in order to achieve this, but strong hypnotic rapport can also alter the individual's reaction to fears and other environmental stresses.
Hypnorelaxation is particularly valuable in the pre- and postoperative emotional preparation of the patient who requires thyroid surgery. Anxious patients can be conditioned for thyroid surgery by a “rehearsal” or a “dry-run” of the proposed surgery (see Chap. 34). The combination of hypnorelaxation and medication after surgery is better than either one alone. Clinicians are aware that the treatment of hyperthyroidism only begins after the surgery is finished. When such individuals are taught to relax, face and understand their difficulties through hypnotherapeutic technics, they become more stabilized, with a better prognosis.
ANOREXIA NERVOSA
The chief symptoms of anorexia nervosa are the loss of appetite and weight, and amenorrhea. Untreated cases have a high mortality. The condition occurs in very highstrung individuals, chiefly women. It must be distinguished from pituitary dysfunction, in which pubic and axillary hair is lost.
Hypnotherapy can be used to keep the patient relaxed in bed, and the appetite can be increased through posthypnotic suggestions associating food with pleasant memories. Concomitantly, feelings of aggression, disgust, and hostility should be ventilated. Crasilneck and Hall cured 50 per cent of their 70 cases by means of hypnosis.
In two cases of anorexia nervosa recently seen by the author, one patient lived and one died. Posthypnotic suggestions of an increase in appetite were accepted by one patient, and there was a subsequent weight gain. This patient, who came in regularly, faced the problems contributing to her depressive reactions. The patient who died of malnutrition did not come in regularly. She had profound guilt feelings and remorse because she had driven her daughter away from home. The daughter became a prostitute, and the mother never forgave herself and masochistically developed an intense need to punish herself.
Bruch has reviewed the literature in this area, and written a monograph on anorexia nervosa.6
BRONCHIAL ASTHMA
There is extensive literature on the psychogenic aspects of asthma.20,26,82 Characteristically, these patients suppress all intense emotions involving threats to their dependent relationships, deprivation, and insecurity induced by sexual conflicts. As children, they are anxiety-ridden, lack confidence and are dependent to an extreme degree. Developmental failures in the functioning of the reticular formation, exacerbated by repeated allergic reactions in the brain stem, have been implicated as an etiologic factor.
Treatment
There is no doubt that suggestion plays a powerful role in asthma. The “rose asthma” case is a classical one in which an asthmatic was exposed to a paper rose under glass, and it precipitated an attack. More recently the experiment was repeated with pulmonary measurements, and over 50 per cent showed a definite increase in airway resistance.
Numerous authors have treated asthma by hypnotherapy.9,12,16,21,33,51,57,58,59,62,73,78 Abreaction under hypnosis may reduce attacks of status asthmaticus. For chronic cases of asthma, autohypnosis together with steroids and evocation of conflicts is often helpful. Asthmatics who became “adrenalin-fast” have been relieved by hypnotherapy directed toward understanding the responsible psychogenic factors.70
In children afflicted with asthma, it has been reported that, in a control series, reassurance by psychotherapy was slower and less certain in its effects than hypnotherapy.56 In both series, parents had to be treated concurrently. Reinforcement suggestions under hypnosis are usually necessary long after recovery has occurred. Parents can be taught to give suggestions to neutralize the anxiety-provoking situations. Sutton taught three patients to use autohypnosis, and all improved.77 For adults, a superficial uncovering type of hypnotherapy often is successful. Prolonged “sleep” can alleviate some severe asthmatic attacks. The author uses relaxation to regulate the breathing, and trains all patients in sensory-imagery conditioning. About 60 per cent of carefully selected cases can be helped by these methods. The reader, however, should not infer that our results would be as dramatic in a random population sample.
MacLaren and Eisenberg studied a group of 50 carefully selected asthmatics who showed no response to medical therapy, and who had overt signs of emotional instability.56 Hostile, skeptical individuals or those who had advanced lung disease were rejected. They noted that if suggestions directed toward the patient's breathing in unison with the operator's counting was followed, the breathing soon became slower and quieter. Strong suggestions of the chest's relaxing usually eliminated breathing difficulties. Sensory-imagery conditioning involving relaxing experiences were employed. Posthypnotic suggestions that the bronchial tubes were opening helped relax the breathing. Scenevisualization technics oriented around the patient's seeing himself in a protected and comfortable position were most effective.
Their results, however, showed a higher number of relapses brought about by exposure to a strong antigen, or respiratory infection. In the emotionally disturbed asthmatics, stress precipitated severe attacks. They concluded that, for more lasting results, threats to the individual's emotional stability had to be uncovered or the person's fears of the threats had to be corrected by psychotherapy.
When fear of choking, which is commonly noted in these patients, was neutralized by reassurance and relaxed breathing exercises, 75 per cent of the relapsed patients improved. Others were asked to ventilate their emotions prior to the attacks. Using an abreactive technic, they had their patients relive anxiety-provoking situations, but without effects. One in eight could not be hypnotized readily, and one in three can be hypnotized but gets little if any benefit. Two out of three get relief, varying from temporary to sustained effects.
Many deaths occur with steroids, and this alone makes the assessment of the potentialities of hypnosis more rather than less urgent. Edwards reports that hypnosis worked by decreasing airways' resistance or by a psychological effect (decreased awareness of airways' resistance).21 Another report extolled the effect of dramatically saving an elderly man's life by hypnosis for a severe case of status asthmaticus.74
One particular observation deserves mention: typical attacks of bronchial asthma were hypnotically produced, and the attacks thus provoked were immediately terminated by appropriate hypnotic suggestions.70 This indicates that bronchial asthma results from a conditioned reflex to harmful external and internal stimulation. African natives, who have a high incidence of tuberculosis, almost never have asthma.
In part, bronchial asthma may be a “neurosis of the lungs.” The expiratory phase in humans is particularly “overloaded” because it underlies the entire complex of speech; hence, breathing is the first manifestation of suffering. The involvement expresses itself as an alteration in the tonus of the smooth muscles of the bronchi.
There are numerous reports of asthma treated by short-term hypnotherapy and behavior modification.50 Soviet scientists believe that the results achieved by hypnosis may be due to “… liberation of the functions of the physiologically lower divisions of the central nervous system and that this may be achieved by inhibition of the higher divisions which normally regulate their work.”70
ALLERGY
Allergic reactions are frequently associated with stress.30,74 Urticaria can be precipitated by traumatic life situations. There are significant differences between acute and chronic urticaria; specific allergens are not present in the latter.71
Hypnosis has been employed to prevent asthmatic attacks in individuals susceptible to certain allergens, even though skin tests remained positive and attacks were produced when these patients were shown an artificial rose or a picture of this. Wheals resulting from a cutaneous reaction to eggs have been suppressed by hypnosis.10 The suppression of allergic skin reactions by hypnosis has not been confirmed.90 However, some researchers have concluded that hypnotic suggestion influences cutaneous allergic reactions.18,47,69
The above data indicate that the widespread use of injections may be because of a placebo effect. Lowell believes that the rationale for injection therapy has not been validated to exclude coincidental factors, chance or bias.55 He states:
… we cannot rule out the possibility of a happy coincidence—the initiation of treatment in a year of less intense exposure to pollen, instruction in allergic cleanliness and in the intelligent use of drugs, the allaying of anxiety, the spontaneous lessening of the patient's level of clinical sensitivity and, last but by no means least, the suggestion that accompanies the ritual of injection therapy. These, individually or in combination, might explain many a success without invoking any specific therapeutic or prophylactic merit for the solution that we put into the syringe.
The author is not surprised at these remarks. When he first began his practice, several hayfever victims had complete relief from placebo medications. He has seen patients with angioneurotic edema, hives, and urticarial reactions who responded to hypnotherapy.
RAYNAUD'S DISEASE
Crasilneck and Hall report a 60 percent remission or improvement rate in Raynaud's disease.14 However, in the absence of controls and the variations due to emotional factors, these investigators caution against over optimism. Others have had similar results.39,63
DISCUSSION
Once again, the author wishes to emphasize that those who benefited from hypnosis are being presented in this section. Failures do occur, and at times the handling of such cases taxes the patience of both patient and therapist. It has been noted that, in most allergic patients, the benefits from hypnosis are not proportionate to the effort involved. However, in tense and anxious ashthmatics, hypnosis reduced fright reactions. However, pulmonary function tests should be used to record actual progress. The reader must realize that results in any condition depend on many variables in the physician and patient rapport. One man gets recoveries and results, while another using the same approach gets only failures.
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15. Dengrove, E.: Behavior therapy of headache. J. Am. Soc. Psychosomat. Dent. Med., 15:41, 1968.
16. Dennis, M., and Phillippus, M.J.: Hypnotic and nonhypnotic suggestion and skin response in atopic patients. Am. J. Clin. Hypn., 7:342, 1965.
17. Dias, M.M.: Hypnosis in irritable colon. Rev. Brasil. Med., 20:132, 1963.
18. Diehl, F., and Heinichen, W.: Beeinfussung allergischer Reaktionen. Munch. Med. Wochenschr 78:1008, 1931.
19. Dorcus, R.M., and Goodwin, P.: The treatment of patients with the dumping syndrome by hypnosis. J. Clin. Exp. Hypn., 3:200, 1955.
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20. Dunbar, H.F.: Emotions and Bodily Changes. ed. 3. New York, Columbia University Press, 1948.
21. Edwards, G.: Hypnotic treatment of asthma. Br. Med. J., 2:492, 1960.
22. Eliot, R.S., and Forker, A.D.: Emotional cardiac disease. J.A.M.A., 236:3325, 1976.
23. Foa, P.P.: The mediation of psychic stimuli and regulation of endocrine function. In Kroger, W.S. (ed.): Psychosomatic Obstetrics. Gynecology and Obstetrics, Springfield, Ill., Charles C Thomas, 1962.
24. Fogelman, M.J., and Crasilneck, H.B.: Food intake and hypnosis J. Am. Deitetic Assoc., 32:519, 1956.
25. Freed, S.C.: Psychic factors in the development and treatment of overweight. J.A.M.A., 133:369, 1947.
26. French, T., and Alexander, F.: Psychogenic factors in bronchial asthma. Psychosom. Med. Monog. Ser., 2:34, 1941.
27. Freidman, A.P.: Migraine and Other Common Headaches. World-Wide Abstracts, September 1959.
28. Friedman, M., and Rosenman, R.: Type A Behavior and Your Heart. New York, Knopf, 1974.
29. Graham, G.W.: Hypnotic treatment for migraine headache. Int. J. Clin. Exp. Hypn., 23:165, 1975.
30. Grant, R.T., Bruce-Pearson R.S., and Comeau, W.J.: Observations on urticaria provoked by emotions, by exercise and by warming the body. Clin. Sci. 2:253, 1936.
31. Hanley, F.W.: Hypnotherapy of migraine. Can. Psychiat. Assoc. J., 9:254, 1964.
32. _________: The treatment of obesity by individual and group hypnosis. Can. Psychiat. Assoc. J., 12:549, 1967.
33. _________: Individualized hypnotherapy of asthma. Am. J. Clin. Hypn., 16:275, 1974.
34. Harding, H.C.: Hypnosis and migraine or vice versa (paper read at the 11th Annual Scientific Meeting of the Society for Clinical and Experimental Hypnosis, San Francisco, August 1959).
35. Hinkle, L.E., Jr., et al.: Studies in diabetes mellitus: the relation of stressful life situations to the concentration of ketone bodies in the blood of diabetic and nondiabetic humans. J. Clin. Invest., 29:754, 1950.
36. Holmes, T.H., et al.: Psychosocial and psychophysiologic studies of tuberculosis. Psychosom. Med., 19:134, 1957.
37. Horan, J.S.: Hypnosis and recorded suggestions in the treatment of migraine. J. Clin. Exp. Hypn., 1:7, 1953.
38. Ivy, A.C.: Motor dysfunction of biliary tract: analytical and critical consideration (Caldwell lecture 1946). Am. J. Roentgenol., 57:1, 1947.
39. Jacobson, A.M., et al.: Raynaud's phenomenon: treatment with hypnotic and operant techniques. J.A.M.A., 225:739, 1973.
40. Kavanaugh, T., et al.: Importance of physical activity in post-coronary rehabilitation. Am. J. Phys. Med., 52:304, 1973.
41. _________: Hypnosis and exercise—a possible combined therapy following myocardial infarction. Am. J. Clin. Hypn., 16:160, 1974.
42. Kline, M.V.: Situational cardiovascular symptomatology and hypnosis. Br. J. Med. Hypn., 1:33, 1950.
43. Kroger, W.S.: New perspectives in obesity: An integrated approach, Int. Rec. Med., 172:212, 1959.
44. _________: Psychologic features in obesity and anorexic drugs. Am. Pract., 10:2169, 1959.
45. _________: A comparison of anorexic drugs in the treatment of the resistant obese patient. J. Psychosomatics, 8:1, 1962.
46. _________: Hypnotherapeutic management of headache. Headache, 2:50, 1963.
47. _________: Current status of hypnosis in allergy. Ann. Allergy, 22:123, 1964.
48. _________: Comprehensive management of obesity. Am. J. Clin. Hypn., 12:165, 1970.
49. _________: Systems approach for understanding obesity: management by behavioral modification through hypnosis. Psychiat. Opin., 7:7, 1970.
50. Kroger, W.S., and Fezler, W.D.: Hypnosis and Behavior Modification: Imagery Conditioning. Philadelphia, J. B. Lippincott, 1976.
51. Kusano, T., et al.: Use and abuse of hypnotherapy for bronchial asthma. Japan J. Hypn., 12:33, 1969.
52. Kupfer, D.: Hypnotherapy in a case of functional heart disorder. J. Clin. Exp. Hypn., 2:186, 1954.
53. Leonard, A.S., et al.: Treatment of post-gastrectomy dumping syndrome by hypnotic suggestion. J.A.M.A., 165:1957, 1957.
54. Levine, S.A.: Some notes concerning angina pectoris. J.A.M.A., 171:1838, 1840, 1959.
55. Lowell, F.C.: American Academy of Allergy: Presidential address. J. Allergy, 31:185, 1960.
56. MacLaren, W.R., and Eisenberg, B.C.: Hypnosis in the treatment of asthma (paper read before the Pan American Medical Association, May 5, 1960).
57. Magonet, A.P.: Hypnosis and asthma. Int. J. Clin. Exp. Hypn., 8:121, 1960.
58. Maher-Loughnan, G.P.: Hypnosis and autohypnosis for the treatment of asthma. Int. J. Clin. Exp. Hypn., 18:1, 1970.
59. Maher-Loughnan, G.P., et al.: Controlled trial of hypnosis in the symptomatic treatment of asthma. Br. Med. J., 2:371, 1962.
60. Moddy, H.: An evaluation of hypnotically induced relaxation for the reduction of peptic ulcer symptoms. Br. J. Med. Hypn., 5:23, 1953.
61. Moorefield, C.W.: The use of hypnosis and behavior therapy in asthma. Am. J. Clin. Hypn., 13:162, 1971.
62. Morton, J.H.: Hypnosis and psychosomatic medicine. Am. J. Clin. Hypn., 3:67, 1960.
63. Norris, A., and Huston, P.: Raynaud's disease studied by hypnosis. Dis. Nerv. Syst., 17:163, 1956.
64. Nuland, W.: The use of hypnotherapy in the treatment of the post-myocardial infarction invalid. Int. J. Clin. Exp. Hypn., 16:139, 1968.
65. _________: Hypnosis and weight control (presentation at annual meeting of the society for Clinical and Experimental Hypnosis, Montreal, 1974).
66. Oakley, R.P.: Hypnosis with a positive approach in the management of “problem” obesity. J. Am. Soc. Psychosom. Dent. Med., 7:28, 1960.
67. Ostfeld, A.M.: Migraine headache, J.A.M.A., 174:110-112, 1960.
68. Ostfeld, A.M., et al.: Studies in headache: a summary of evidence implicating a locally active chemical agent in migraine. Trans. Am. Neurol. Assoc., 81st meeting, 1956, p. 356.
69. Perloff, M.M., and Spiegelman, J.: Hypnosis in the treatment of a child's allergy to dogs. Am. J. Clin. Hypn., 15:269, 1973.
70. Platonov, K.: The Word As a Physiological and Therapeutic Factor. Moscow, Foreign Languages Publishing House, 1955.
71. Raginsky, B.B.: In Schneck, J.M. (ed.): Hypnosis in Modern Medicine. Springfield, Ill., Charles C Thomas, 1959.
72. Robinson, W.D.: In Hollander, J.L. (ed.): Arthritis and Allied Conditions. Philadelphia, Lea & Febiger, 1966.
73. Rose, S.: A general practitioner approach to the asthmatic patient. Am. J. Clin. Hypn., 10:30, 1967.
74. Saul, L.J., and Bernstein, G., Jr.: The emotional settings of some attacks of urticaria. Psychosom. Med., 3:349, 1941.
75. Sinclair-Gieben, A.H.C.: Treatment of status asthmaticus by hypnosis. Br. Med. J., 2:1651, 1960.
76. Sparer, P.J.: Personality, Stress and Tuberculosis. New York, International Universities Press, 1956.
77. Stanton, H.: Weight loss through hypnosis. Am. J. Clin. Hypn., 18:34, 1975.
78. Sutton, P.H.: A trial of group hypnosis and autohypnosis in asthmatic children. Br. J. Clin. Hypn., 1:1, 1969.
79. Tilker, H.A., and Meyer, R.G.: The use of covert sensitization and hypnotic procedures in the treatment of an overweight person: a case report. Am. J. Clin. Hypn., 15:15, 1972.
80. Traut, E.F., and Passarelli, E.W.: Placebo and the treatment of rheumatoid arthritis and other rheumatoid conditions. Ann. Rheumat. Dis., 18:21, 1957.
81. Tullis, I.F.: Rational diet construction for mild and grand obesity. J.A.M.A., 226:70, 1973.
82. Vaughan, W.T.: Practice of Allergy. St. Louis, C.V. Mosby, 1939.
83. Wick, E., et al.: Hypnotherapy and therapeutic education in the treatment of obesity: differential treatment factors. Psychiat. Q. 45:234, 1971.
84. Wolberg, L.R.: Medical Hypnosis. vol. 1. New York, Grune & Stratton, 1948.
85. Wolff, H.G.: Headache and Other Head Pain. New York, Oxford University Press, 1948.
86. Wollman, L.: Hypnosis and weight control. Am. J. Clin. Hypn., 4:177, 1962.
87. Wright, M.E.: Hypnotherapy and psychosomatic hypotheses. Am. J. Clin. Hypn., 8:245, 1966.
88. Yanovski, A.G.: The feasibility of alteration of cardiovascular manifestations in hypnosis. Am. J. Clin. Hypn., 5:8, 1962.
89. Zane, M.D.: The hypnotic situation and changes in ulcer pain. Int. J. Clin. Exp. Hypn., 14:292, 1966.
90. Zeller, M.: Influence of hypnosis on passive transfer and skin tests. Ann. Allergy, 2:515, 1944.